SWAL-QOL 1 Below are some general statements that people with swallowing problems might mention. In the last month, how true have the following statements been for you? Please select one answer per statement. Degree of Problem 0 - 5 Rating Scale 0 = Never1 = Very much True2 = Quite a bit True3 = Somewhat True4 = A Little True5 = Not at all True Dealing with my swallowing problem is very difficult. 0 1 2 3 4 5 None 2 Below are aspects of day-to-day eating that people with swallowing problems sometimes talk about. In the last month, how true have the following statements been for you? Please select one answer per statement. Degree of Problem 0 - 5 Rating Scale 0 = Never1 = Very much True2 = Quite a bit True3 = Somewhat True4 = A Little True5 = Not at all True My swallowing problem is a major distraction in my life. 0 1 2 3 4 5 None 3 Below are aspects of day-to-day eating that people with swallowing problems sometimes talk about. In the last month, how true have the following statements been for you? Please select one answer per statement. Degree of Problem 0 - 5 Rating Scale 0 = Never1 = Very much True2 = Quite a bit True3 = Somewhat True4 = A Little True5 = Not at all True Most days, I don’t care if I eat or not. 0 1 2 3 4 5 None 4 Below are aspects of day-to-day eating that people with swallowing problems sometimes talk about. In the last month, how true have the following statements been for you? Please select one answer per statement. Degree of Problem 0- 5 Rating Scale 0 = Never1 = Very much True2 = Quite a bit True3 = Somewhat True4 = A Little True5 = Not at all True I’m rarely hungry anymore. 0 1 2 3 4 5 None 5 Below are aspects of day-to-day eating that people with swallowing problems sometimes talk about. In the last month, how true have the following statements been for you? Please select one answer per statement. Degree of Problem 0 - 5 Rating Scale 0 = Never1 = Very much True2 = Quite a bit True3 = Somewhat True4 = A Little True5 = Not at all True I don’t enjoy eating anymore. 0 1 2 3 4 5 None 6 Below are aspects of day-to-day eating that people with swallowing problems sometimes talk about. In the last month, how true have the following statements been for you? Please select one answer per statement. Degree of Problem 0 - 5 Rating Scale 0 = Never1 = Very much True2 = Quite a bit True3 = Somewhat True4 = A Little True5 = Not at all True It takes me longer to eat than other people. 0 1 2 3 4 5 None 7 Below are some physical problems that people with swallowing problems sometimes experience. In the last month, how often you have experienced each problem as a result of your swallowing problem? Degree of Problem 0 - 5 Rating Scale 0 = Never1 = Almost Always2 = Often3 = Sometime4 = Hardly 5 = Never It takes me forever to eat a meal. 0 1 2 3 4 5 None 8 Below are some physical problems that people with swallowing problems sometimes experience. In the last month, how often you have experienced each problem as a result of your swallowing problem? Degree of Problem 0 - 5 Rating Scale 0 = Never1 = Almost Always2 = Often3 = Sometime4 = Hardly 5 = Never Coughing 0 1 2 3 4 5 None 9 Below are some physical problems that people with swallowing problems sometimes experience. In the last month, how often you have experienced each problem as a result of your swallowing problem? Degree of Problem 0 - 5 Rating Scale 0 = Never1 = Almost Always2 = Often3 = Sometime4 = Hardly 5 = Never Choking when you eat food 0 1 2 3 4 5 None 10 Below are some physical problems that people with swallowing problems sometimes experience. In the last month, how often you have experienced each problem as a result of your swallowing problem? Degree of Problem 0 - 5 Rating Scale 0 = Never1 = Almost Always2 = Often3 = Sometime4 = Hardly 5 = Never Choking when you take liquids 0 1 2 3 4 5 None 11 Below are some physical problems that people with swallowing problems sometimes experience. In the last month, how often you have experienced each problem as a result of your swallowing problem? Degree of Problem 0 - 5 Rating Scale 0 = Never1 = Almost Always2 = Often3 = Sometime4 = Hardly 5 = Never Having thick saliva or phlegm 0 1 2 3 4 5 None 12 Below are some physical problems that people with swallowing problems sometimes experience. In the last month, how often you have experienced each problem as a result of your swallowing problem? Degree of Problem 0 - 5 Rating Scale 0 = Never1 = Almost Always2 = Often3 = Sometime4 = Hardly 5 = Never Gagging 1 2 3 4 5 None 13 Below are some physical problems that people with swallowing problems sometimes experience. In the last month, how often you have experienced each problem as a result of your swallowing problem? Degree of Problem 0 - 5 Rating Scale 0 = Never1 = Almost Always2 = Often3 = Sometime4 = Hardly 5 = Never Drooling 0 1 2 3 4 5 None 14 Below are some physical problems that people with swallowing problems sometimes experience. In the last month, how often you have experienced each problem as a result of your swallowing problem? Degree of Problem 0 - 5 Rating Scale 0 = Never1 = Almost Always2 = Often3 = Sometime4 = Hardly 5 = Never Problems chewing 0 1 2 3 4 5 None 15 Below are some physical problems that people with swallowing problems sometimes experience. In the last month, how often you have experienced each problem as a result of your swallowing problem? Degree of Problem 1 - 5 Rating Scale 0 = Never1 = Almost Always2 = Often3 = Sometime4 = Hardly 5 = Never Having excess saliva or phlegm 0 1 2 3 4 5 None 16 Below are some physical problems that people with swallowing problems sometimes experience. In the last month, how often you have experienced each problem as a result of your swallowing problem? Degree of Problem 0 - 5 Rating Scale 0 = Never1 = Almost Always2 = Often3 = Sometime4 = Hardly 5 = Never Having to clear your throat 0 1 2 3 4 5 None 17 Below are some physical problems that people with swallowing problems sometimes experience. In the last month, how often you have experienced each problem as a result of your swallowing problem? Degree of Problem 0 - 5 Rating Scale 0 = Never1 = Almost Always2 = Often3 = Sometime4 = Hardly 5 = Never Food sticking in your throat 0 1 2 3 4 5 None 18 Below are some physical problems that people with swallowing problems sometimes experience. In the last month, how often you have experienced each problem as a result of your swallowing problem? Degree of Problem 0 - 5 Rating Scale 0 = Never1 = Almost Always2 = Often3 = Sometime4 = Hardly 5 = Never Food sticking in your mouth 0 1 2 3 4 5 None 19 Below are some physical problems that people with swallowing problems sometimes experience. In the last month, how often you have experienced each problem as a result of your swallowing problem? Degree of Problem 0 - 5 Rating Scale 0 = Never1 = Almost Always2 = Often3 = Sometime4 = Hardly 5 = Never Food or liquid dribbling out of your mouth 0 1 2 3 4 5 None 20 Below are some physical problems that people with swallowing problems sometimes experience. In the last month, how often you have experienced each problem as a result of your swallowing problem? Degree of Problem 0 - 5 Rating Scale 0 = Never1 = Almost Always2 = Often3 = Sometime4 = Hardly 5 = Never Food or liquid coming our your nose 0 1 2 3 4 5 None 21 Next, please answer a few questions about how your swallowing problem has affected your diet and eating in the last month. Degree of Problem 0 - 5 Rating Scale 0 = Never1 = Strongly agree2 = Agree3 = Uncertain4 = Disagree 5 = Strongly disagree Coughing food or liquid out of your mouth when it gets stuck 0 1 2 3 4 5 None 22 Next, please answer a few questions about how your swallowing problem has affected your diet and eating in the last month. Degree of Problem 0 - 5 Rating Scale 0 = Never1 = Strongly agree2 = Agree3 = Uncertain4 = Disagree 5 = Strongly disagree Figuring out what I can and can’t eat is a problem for me. 0 1 2 3 4 5 None 23 In the last month, how often have the following statements about communication applied to you because of your swallowing problem? Degree of Problem 0 - 5 Rating Scale 0 = Never1 = All of the time2 = Most of the time3 = Some of the time4 = A little of the time5 = None of the time It is difficult to find foods that I both like and can eat. 0 1 2 3 4 5 None 24 In the last month, how often have the following statements about communication applied to you because of your swallowing problem? Degree of Problem 0 - 5 Rating Scale 0 = Never1 = All of the time2 = Most of the time3 = Some of the time4 = A little of the time5 = None of the time People have a hard time understanding me. 0 1 2 3 4 5 None 25 Below are some concerns that people with swallowing problems sometimes mention. In the last month, how often have you experienced each feeling? Degree of Problem 0 - 5 Rating Scale 0 = Never1 = All of the time2 = Most of the time3 = Some of the time4 = A little of the time5 = None of the time It’s been difficult for me to speak clearly. 0 1 2 3 4 5 None 26 Below are some concerns that people with swallowing problems sometimes mention. In the last month, how often have you experienced each feeling? Degree of Problem 0 - 5 Rating Scale 0 = Never1 = All of the time2 = Most of the time3 = Some of the time4 = A little of the time5 = None of the time I fear I may start choking when I eat food. 0 1 2 3 4 5 None 27 Below are some concerns that people with swallowing problems sometimes mention. In the last month, how often have you experienced each feeling? Degree of Problem 0 - 5 Rating Scale 0 = Never1 = All of the time2 = Most of the time3 = Some of the time4 = A little of the time5 = None of the time I worry about getting pneumonia. 0 1 2 3 4 5 None 28 Below are some concerns that people with swallowing problems sometimes mention. In the last month, how often have you experienced each feeling? Degree of Problem 0 - 5 Rating Scale 0 = Never1 = All of the time2 = Most of the time3 = Some of the time4 = A little of the time5 = None of the time I am afraid of choking when I drink liquids. 0 1 2 3 4 5 None 29 In the last month, how often have the following statements been true for you because of your swallowing problem? Degree of Problem 0 - 5 Rating Scale 0 = Never1 = Always true 2 = Often true3 = Sometimes true4 = Hardly ever true5 = Never true I never know when I am going to choke. 0 1 2 3 4 5 None 30 In the last month, how often have the following statements been true for you because of your swallowing problem? Degree of Problem 0 - 5 Rating Scale 0 = Never1 = Always true 2 = Often true3 = Sometimes true4 = Hardly ever true5 = Never true My swallowing problem depresses me. 0 1 2 3 4 5 None 31 In the last month, how often have the following statements been true for you because of your swallowing problem? Degree of Problem 0 - 5 Rating Scale 0 = Never1 = Always true 2 = Often true3 = Sometimes true4 = Hardly ever true5 = Never true Having to be so careful when I eat or drink annoys me. 0 1 2 3 4 5 None 32 In the last month, how often have the following statements been true for you because of your swallowing problem? Degree of Problem 0 - 5 Rating Scale 0 = Never1 = Always true 2 = Often true3 = Sometimes true4 = Hardly ever true5 = Never true I’ve been discouraged by my swallowing problem. 0 1 2 3 4 5 None 33 In the last month, how often have the following statements been true for you because of your swallowing problem? Degree of Problem 0 - 5 Rating Scale 0 = Never1 = Always true 2 = Often true3 = Sometimes true4 = Hardly ever true5 = Never true My swallowing problem frustrates me. 0 1 2 3 4 5 None 34 Think about your social life in the last month. How strongly would you agree or disagree with the following statements? Degree of Problem 0 - 5 Rating Scale 0 = Never1 = Strongly Agree 2 = Agree3 = Uncertain4 = Disagre5 = Strongly disagree I get impatient dealing with my swallowing problem. 0 1 2 3 4 5 None 35 Think about your social life in the last month. How strongly would you agree or disagree with the following statements? Degree of Problem 0 - 5 Rating Scale 0 = Never1 = Strongly Agree2 = Agree3 = Uncertain4 = Disagre5 = Strongly disagree I do not go out to eat because of my swallowing problem. 0 1 2 3 4 5 None 36 Think about your social life in the last month. How strongly would you agree or disagree with the following statements? Degree of Problem 0 - 5 Rating Scale 0 = Never1 = Strongly Agree2 = Agree3 = Uncertain4 = Disagre5 = Strongly disagree My swallowing problem makes it hard to have a social life. 0 1 2 3 4 5 None 37 Think about your social life in the last month. How strongly would you agree or disagree with the following statements? Degree of Problem 0 - 5 Rating Scale 0 = Never1 = Strongly Agree2 = Agree3 = Uncertain4 = Disagre5 = Strongly disagree My usual work or leisure activities have changed because of my swallowing problem. 0 1 2 3 4 5 None 38 Think about your social life in the last month. How strongly would you agree or disagree with the following statements? Degree of Problem 0 - 5 Rating Scale 0 = Never1 = Strongly Agree2 = Agree3 = Uncertain4 = Disagre5 = Strongly disagree Social gatherings (like holidays or get-togethers) are not enjoyable because of my swallowing problem. 0 1 2 3 4 5 None 39 In the last month, how often have you experienced each of the following physical symptoms? Degree of Problem 0 - 5 Rating Scale 0 = Never1 = All of the time 2 = Most of the time3 = Some of the time 4 = A little of the time5 = None of the time. My role with my family and friends has changed because of my swallowing problem. 0 1 2 3 4 5 None 40 In the last month, how often have you experienced each of the following physical symptoms? Degree of Problem 0 - 5 Rating Scale 0 = Never1 = All of the time 2 = Most of the time3 = Some of the time 4 = A little of the time5 = None of the time. Feel weak? 0 1 2 3 4 5 None 41 In the last month, how often have you experienced each of the following physical symptoms? Degree of Problem 0 - 5 Rating Scale 0 = Never1 = All of the time 2 = Most of the time3 = Some of the time 4 = A little of the time5 = None of the time. Have trouble falling asleep? 0 1 2 3 4 5 None 42 In the last month, how often have you experienced each of the following physical symptoms? Degree of Problem 0 - 5 Rating Scale 0 = Never1 = All of the time 2 = Most of the time3 = Some of the time 4 = A little of the time5 = None of the time. Feel tired? 0 1 2 3 4 5 None 43 In the last month, how often have you experienced each of the following physical symptoms? Degree of Problem 0 - 5 Rating Scale 0 = Never1 = All of the time 2 = Most of the time3 = Some of the time 4 = A little of the time5 = None of the time. Have trouble staying asleep? 0 1 2 3 4 5 None 44 Below are some general statements that people with swallowing problems might mention. In the last month, how true have the following statements been for you? Please select one answer per statement. Degree of Problem 0 - 5 Rating Scale 0 = Never1 = Very much True2 = Quite a bit True3 = Somewhat True4 = A Little True5 = Not at all True Feel exhausted? 0 1 2 3 4 5 None Name DOB Email Phone number Please contact me by email Please contact me by phone Time's up
